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REVIEW ARTICLE Open Journal of & Allied Sciences

Dhat syndrome: past and present - the journey of an Indian culture-bound syndrome across the globe

Dhrubajyoti Bhuyan1, Abstract Bikashita Deka2 Dhat syndrome, originally thought to be a culture-bound syndrome restricted to the 1Assistant Professor, Department of Psychiatry, Indian subcontinent, has now been found to be spread worldwide. This “semen-loss Assam Medical College Hospital, Dibrugarh, ” is excessive preoccupation with loss of vitality resulting from loss of semen Assam, India, 2Postgraduate Trainee, either through urination, , or . Semen has been linked Department of Psychiatry, Assam Medical to strength and power in the Ayurveda. The ethno-cultural beliefs of a community College Hospital, Dibrugarh, Assam, India are important in shaping the expression of underlying psychological disturbances. In developing countries, the repressed emotions usually find expression through somatic symptoms. The presentations can range from depression, anxiety, Correspondence: Dr. Dhrubajyoti Bhuyan, MD, fatigability, , and other somatic symptoms. Dhat syndrome is Assistant Professor, Department of Psychiatry, akin to shen-k-uei in China and Taiwan and shukra prameha in . Even Assam Medical College Hospital, Barbari, in the seventeenth century west, the nobility distinguished themselves from the Dibrugarh, Assam, India, PIN-786002. common by way of sexual sanctity. This poses a question to the usual assumption [email protected] that Dhat syndrome arose in the east and was prevalent among the less educated classes only. The lack of understanding of the phenomenology and a deficient Received: 6 November 2017 universal language of reporting has made it difficult to be placed under any specific Revised: 24 November 2018 category in the diagnostic system. The tenth revision of the International Statistical Accepted: 27 November 2018 Classification of Diseases and Related Health Problems (ICD-10) mentions Dhat Epub: 12 January 2019 syndrome under other unspecified neurotic disorders (F48.8) while the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions DOI: 10.5958/2394-2061.2019.00021.1 it under “the cultural concepts of distress.” A better understanding of the disorder requires a comprehensive approach and integration with allied system of as well as community awareness is required to address this problem.

Keywords: Semen. Anxiety. Sexual Dysfunction.

INTRODUCTION HISTORY The word dhat has been derived from the dhatu, The ancient system of evolution of medicine in India has been which means metal. Dhat syndrome or “semen-loss greatly influenced by Ayurveda, and the meaning attributed anxiety” is the excessive preoccupation with loss of vitality to semen by Ayurveda has been inculcated deeply into the and strength attributed to semen loss either through psyche of generations that followed. Seven dhatus or tissues masturbation, nocturnal emission, loss through urine or has been described in Ayurveda medicine; plasma (rasa), stool. It presents as anxiety, mood symptoms, or somatic blood (rakta), muscle (mamsa), fat (medas), bone marrow symptoms.[1] Though initially thought to be a culture- (asthi), nerve (majja), and reproductive tissue (shukra). bound syndrome restricted to the Indian subcontinent, Semen or dhatu has been called the elixir of life. It has also cases of Dhat syndrome have been reported from various been called shukra or virya. Whatever be the colloquial countries across the globe.[2] In China, it is known as, term used, the bottom-line is that semen represents vitality shen-k-uei. In Sri Lanka, it is known as shukra prameha. and masculinity. It is said that it takes 40 days for 40 drops This shows the pervasive and unequivocal nature of of food to be converted into blood and 40 drops of blood to the illness.[3] Cross-cultural research has led to the be converted into a drop of flesh, 40 drops of which is then finding that the basic psychopathology in culture-bound converted to drop of fat which is then converted to marrow syndrome is the same. The symptomatology and natural and this marrow is distilled into semen.[4] Hence, semen loss history depend upon the prevalent belief system relevant can be traced back to the ultimate loss of most of the other to a particular community. In this regard, mention may be dhatus as well. Some schools also believe that made of disorders such as brain-fag, , bilis, hwa-byung, leads to loss of cavernosal blood. TheCharaka Samhita neurasthenia, and latah to name a few. They are common also mentions about the damage to the dhatus as a result of in their shared presentation as somatic complaints; hence, excessive ejaculation. Hence, semen has been explained to be a often called somatisation. concentrate of energy and thus, loss of semen is likened to loss Bhuyan and Deka of energy, in the Indian context. Professor NN Wig has been was considered as accompanying the primary symptoms credited for coining the term Dhat syndrome for the group of of mood or anxiety disorder. symptoms attributed to the semen loss and has recognised it 3. Dhat with comorbid sexual dysfunction. as an important Indian culture-bound syndrome. Going through review literatures, it can be viewed CULTURAL BELIEF SYSTEM AND DHAT that Dhat syndrome is mostly prevalent in young males in their second to third decade, who have had little formal SYNDROME years of schooling and those who belong to the rural areas Culture can be called a set of beliefs, norms, and values that of the Indian subcontinent. Studies have shown that there are specific to a geographical location and are followed by the exists a relationship between the demographic profile and collective population in that area.[5] Cultural practices are symptomatology. Younger men, lesser years of education, essential in the understanding of psychological disturbances unmarried men report greater anxiety, depressive, and because it attempts to differentiate the impact of environment hypochondriacal symptoms compared to their counterparts. It and social background in the causation of an illness from can be assumed that in young males there remains considerable biological underpinnings. The ethno-cultural beliefs are pressure regarding sexuality as they enter into adulthood important in explaining the symptomatology of culture- and this pressure is reinforced by the taboo surrounding bound illnesses, e.g. in the third world countries, where the discussion about sexuality and proper understanding of the concept of psychological wellness is yet to be promulgated, same. Hence, there is little chance of the traditional beliefs psychological disturbances often find their expression in the to be confronted resulting in an even more firm foothold. form of somatic symptoms.[6-8] Dhat syndrome is considered The dissipation of these beliefs across cultures and ethnicity by many authors as a ramification of somatization disorders. can be considered one of the causes of Dhat syndrome being There is a pervasive system of cultural beliefs regarding the reported from across the globe. However, reports have been cause and effect of the illness. People usually attribute the there of Dhat syndrome in females as well.[9] They present illness to excessive use of pornographic material, betrayal in with unexplained aches, pains, and fatigability attributed to friendship or love, or excessive longing for sexual relationships. the passage of non-foul smelling, non-itchy vaginal discharge. The belief system even incorporates physical ailments such as They would associate relief of the physical symptoms with the urinary tract infection (UTI), venereal disease, constipation, diminishing of vaginal discharge just after menstruation and dearth of sleep, and overeating to be a cause. In turn, Dhat increase in the frequency and intensity of physical symptoms syndrome is believed to lead to development of malformed concurrent with increased passage of vaginal discharge. foetus, birth of female child, early ageing, and other medical Psychodynamic studies also revealed interpersonal conflicts conditions like tuberculosis and leprosy. The ejaculate is in few of the reported cases of female Dhat syndrome.[11] thought either to be concentrated urine, pus or concentrated As a deviation from the accepted age group of youth which blood. In the olden days, it was also called phosphaturia as is thought to be affected, childhood masturbation is more phosphate was thought to be lost along with semen. As the common than is apparent and the diagnosis is often difficult. perceived cause and effect of the illness is largely unfounded Childhood masturbation has been commoner in girls than in the cultural context, it is quite customary for the affected in boys and during the episode, flushing, sweating, trunk population to approach traditional modalities of treatment, thrusting, and dystonic posturing may be present. It usually such as herbs and aphrodisiacs. It is not uncommon to see manifests as fatigue and changes in the sleep-wake pattern. hakims and vaids advertising claims of cure for this syndrome Manipulation of the genitals is not always present and in pamphlets and hoardings. Some go a step further even to epilepsy, colic, and movement disorders need to be ruled consider marriage to be a cure.[9] Apart from Hindus, it is out which can pose a diagnostic dilemma. Such reports have equally prevalent among the Sikhs in Punjab, the Buddhists been there from the Iranian society where sex outside of in Sri Lanka, and the Muslims in Pakistan. marriage is a taboo and the major route of obtaining sexual pleasure is through masturbation. But, the pathophysiology is VARIOUS PRESENTATIONS AND unexplained and children as young as below one year of age DEMOGRAPHIC CORRELATES are seen to be affected.[12] The presentation in Dhat syndrome varies widely. They Spilling over from the Indian subcontinent, cases have include fatigability, anxiety, depressive, or other somatic been reported from countries like Pakistan, Bangladesh, symptoms. and Nepal, Sri Lanka, China, Malaysia, Japan, America, and are frequent associations.[9] Whether they are presentation of Russia.[5] Mardana kamzori is the generic term used Dhat syndrome or are a part of comorbidity is not yet certain in Pakistan for the illness and has similar presentation. due to the lack of a concrete pathophysiological basis. Some However, cases from Pakistan are underreported for the authors like to call it a variant of depressive disorder while taboo surrounding sex and the sufferers are seen to approach few others like to call it a variant of somatization disorder. traditional practitioners of medicine.[13] In this regard, the Patients with the disorder can be divided into the following ubiquity of the illness can be stressed upon. categories:[10] There is lack of a specific definition or diagnostic criteria 1. Dhat alone presents with depressive, anxiety, or for Dhat syndrome. It is loosely termed as excessive concern hypochondriacal symptoms and these are attributed over semen loss which can happen through various routes. solely to semen loss. Most authors describe the presenting neurotic complaints as 2. Dhat with comorbid depression and anxiety where Dhat being comorbidities. Depression is most commonly reported

102 OJPAS® | Volume 10 | Issue 2 | July-December 2019 Dhat syndrome with prevalence ranging from 40-60%. There have been reports Corn Flakes can be traced back to their belief to curb one’s of suicidal attempt in patients with Dhat syndrome.[14] desire to masturbate. However, in ancient Rome and Greece, Anxiety symptoms are reported in 21-38%. Somatoform and sexual expression and satisfaction was treated as being hypochondriacal symptoms are reported in as high as 40%. natural and necessary akin to hunger and thirst. Perhaps, the Other psychiatric comorbidities include obsessive disorders, reason behind the concern over semen loss across cultures is body dysmorphic disorders, and delusional disorders among the innate purpose of humans to procreate and populate the others.[15] earth. This apprehension can thus be rooted back to a threat to survival and the dwindling away of human race. INDIAN CULTURE-BOUND SYNDROME OR UNIVERSAL SYNDROME CONTROVERSIES The previous assumption that culture-bound syndromes India, in the Vedic age, was liberal in sexual expression. Kama basically arose in the east and are found among the uncivilised sutra, written somewhere between the first and the sixth can be challenged by the fact that Dhat syndrome has been century mentions the three pillars of : dharma reported from various parts of the world.[3] In China, (religious duties), artha (worldly welfare), and kama (sensual shen-k-uei has been described as a kind of sexual neurosis aspects). The carvings in the Ajanta Ellora caves and the open where individuals complain of dizziness, fatigue, and mood depiction of female nudity through art and sculpture in South symptoms due to loss of semen either by sexual intercourse, India point towards liberalism. The Indian civilisation had seen masturbation, nocturnal emission, or through urine. Chinese a significant change in appreciation of sexuality over the years. culture holds the belief that women are capable of stealing After colonisation by the British, a significant change of attitude semen from men and hence, their vitality. There is thus an was observed with the rigid Victorian values dominating the imbalance between yin and yang which ultimately leads to scenario. The earlier more rational and open mindedness disease. Various practices were in vogue in order to prevent towards the expression of sexual instincts had given way to the loss of yang and gain of yin, i.e. the female sexual energy, more rigid and conservative approach.[19] A collateral change e.g. enabling the woman to and avoiding ejaculation in the culture-specific beliefs can be postulated hinging on it. with the penis still inside the vagina, thereby acquiring the For example, Dhat syndrome came into being along with the released orgasmic energy from the female. Another practice development of a more orthodox face of sexuality in India. called the huan ching pu nao involved positive thinking to help Again, in the western world, there has been a reverse in the semen ascend up to the brain and bring vitality to other body scenario. Syndromes akin to Dhat had been described in parts. Similar cases of shen-k-uei have been reported from literature from yesteryears when discussions related to sex Taiwan. In Sri Lanka, shukra prameha has been described as were a taboo. However, in the years that followed, with the being similar to Chinese shen-k-uei. more rational understanding the reports of sexual neurosis had become infrequent. However, the west is not immune to Semen and virility has been linked from the time of culture-bound syndromes. Anorexia nervosa is considered Hippocrates and Aristotle. In the western culture too, loss a western culture-bound syndrome. The demands of specific of semen by means other than sexual intercourse with a occupation such as ballet, swimming, or acting require a lean woman has been embodied as sinful, even accountable frame. Also, some religion like the Gnostic sect of Christianity for death sentence. In the seventeenth century, in the west, used to practice self-starvation as a form of asceticism and the middle class began distinguishing themselves from the for attaining salvation by suppressing the natural phenomena nobility and the poorer section through their way of sexual of hunger and gaining control. They used to term it “Holy sanctity while promiscuity was though to be rampant in the Anorexia”. Moreover, the unnecessary hype created by the other two classes. As there was rise of the bourgeoisie as media regarding the perfect physique has led to more and more the ruling class through sheer dint of hard work, they were people falling victims to it.[20] Earlier considered exotic to the orthodox with regards to their sexual habits. They viewed west, anorexia nervosa is now spreading across the globe with masturbation and semen loss with contempt and considered more and more cases being reported from India and Asia at it an unnecessary waste of energy. However, the aristocratic large. This can be attributed to the intermingling of cultures and class who rose in order by way of inheritance seemed to be traditions as the world is being transformed into a global village less stringent regarding the same because it seemed they had through better means of communication and information easy affluence[16] and had very little to lose. During this time, exchange. In the same manner, the once considered “neurosis Tissot’s A Treatise on the Disease Produced by Onanism was of the orient”, Dhat syndrome permeated across culture and published linking masturbation to disease. Simultaneously, geography with cases being reported from across the globe. masturbatory hysteria developed and anti-masturbatory campaigns were undertaken and semen loss was considered CURRENT NOSOLOGY to be detrimental to the masculinity of men, posing a serious threat to social order. Masturbatory habits marked a loss Dhat syndrome has been mentioned under other unspecified of control over instinctual urges and posed as derogatory neurotic disorders (F48.8) in the International Statistical to one’s masculinity.[17] Graham[18] viewed semen as the Classification of Diseases and Related Health Problems essential oil of animal liquors required for optimal mental (ICD-10).[21] Other conditions placed under the same heading and biological functioning. Reverend Sylvester Graham and are koro (anxiety that penis will retract into the abdomen John Harvey Kellogg were of the opinion that masturbation is and cause death), latah (imitative and automatic response detrimental to health and each time a male ejaculates, he loses behaviour), occupational neurosis, including writer’s cramp, vital energy and origin of Graham crackers and Kellogg’s psychasthenia, psychasthenia neurosis, and psychogenic

OJPAS® | Volume 10 | Issue 2 | July-December 2019 103 Bhuyan and Deka syncope. All of them have a strong cultural underpinning and Psychiatry. 2015;57:255-61. hence, steer clear of the classification of delusional disorders. 2. Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry. 2007;49:208-10. The fifth edition of the Diagnostic and Statistical Manual of 3. Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound Mental Disorders (DSM-5) explains the disorder under “the syndromes: the story of dhat syndrome. Br J Psychiatry. cultural concepts of distress”.[22] The fourth edition of DSM 2004;184:200-9. (DSM-IV) has mentioned culture bound syndrome only in the 4. Akhtar S. Four culture-bound psychiatric syndromes in India. Int J Soc Psychiatry. 1988;34:70-4. appendix as “recurrent locality specific patterns of aberrant 5. Kar SK, Sarkar S. Dhat syndrome: evolution of concept, current behavior and troubling experience that may or may not be understanding, and need of an integrated approach. J Hum linked to particular DSM-IV category”.[23] Reprod Sci. 2015;8:130-4. 6. Baasher TA. The influence of culture on psychiatric The placement of culture-bound syndromes in a specific manifestations. Transcult Psychiatry. 1963;15:51-2. category in the DSM or ICD system of classification is 7. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern problematic not only due to a lack of understanding of the Med. 1999;130:910-21. phenomenology of these syndromes but also due to absence 8. Helman CG. Culture, health and illness: an introduction for health professionals. 2nd ed. London: Wright; 1990. of a common language of reporting the symptoms. Such 9. Prakash S, Sharan P, Sood M. A study on phenomenology of syndromes are geographically and culturally restricted and Dhat syndrome in men in a general medical setting. Indian J though certain common symptomatology exists between Psychiatry. 2016;58:129-41. them, to put into an international system of classification is 10. Avasthi A, Nehra R. Sexual disorders: a review of Indian research. In: Murthy RS, editors. Mental health in India (1995- a hefty challenge. Another major hurdle is the distinction 2000): people’s action for mental health. Bangalore, India; of “essential” from “accessory” symptoms. Different schools 2001:42-53. have different views regarding whether Dhat syndrome is an 11. Grover S, Kate N, Avasthi A, Rajpal N, Umamaheswari V. entity in itself with comorbid appearance of depressive and Females too suffer from Dhat syndrome: a case series and anxiety symptoms or it is an extension of these neuroses. revisit of the concept. Indian J Psychiatry. 2014;56:388-92. 12. Tashakori A, Safavi A, Neamatpour S. Lessons learned from This is another limitation. Moreover, the natural course and the study of masturbation and its comorbidity with psychiatric outcome is yet to be defined.[15] According to Guarnaccia disorders in children: the first analytic study. Electron . and Rogler,[24] the following four fields are to be explored in 2017;9:4096-100. any research on culture-bound syndromes: 13. Khan N. Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry. 2005;47:54-57. 1. A definition of the illness together with a 14. Bhuyan D, Nayek S. A case of Dhat syndrome presenting with phenomenological outline needs to be laid down. suicidal attempt. IOSR J Humanities Soc Sci. 2016;21(4):76-8. 2. The social, cultural, economic, spiritual, or situational 15. Deb KS, Balhara YP. Dhat syndrome: a review of the world events that predisposes, precipitates, or propagates the literature. Indian J Psychol Med. 2013;35:326-31. illness needs to be described. 16. Crossman, A. Overview of the history of sexuality [Internet]. ThoughtCo. 2017 Jul 8 [cited 2017 Nov 6]. Available from: 3. It has to be examined whether these culture-bound https://www.thoughtco.com/history-of-sexuality-3026762. syndromes are psychiatric disorders at all or if there is 17. Garlick S. Masculinity, pornography, and the history of any relationship with other psychiatric disorders. masturbation. Sex Cult. 2012;16:306-20. 4. If a culture-bound syndrome and a psychiatric disorder 18. Graham S. A lecture to young men, on chastity. Providence, RI: Weeden and Cory; 1834. coexist, the link between onset of both, the natural course 19. Chakraborty K, Thakurata RG. Indian concepts on sexuality. of both, and the influence of one disorder on the other in Indian J Psychiatry. 2013 Jan;55(Suppl 2):S250-5. the natural history is to be looked into. 20. Banks CG. ‘Culture’ in culture-bound syndromes: the case of anorexia nervosa. Soc Sci Med. 1992;34:867-84. 21. World Health Organization. The ICD -10 classification of mental FUTURE DIRECTIONS and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. A better handling of this sensitive disorder requires an 22. American Psychiatric Association. Diagnostic and statistical integrated approach. Integration with the traditional system of manual of mental disorders. 5th ed. Arlington, VA: American medicine, with allied health professionals as well as with other Psychiatric Association; 2013. disciplines is necessary to tackle it at the root. The importance 23. American Psychiatric Association. Diagnostic and statistical of constructive education and imparting sex education at manual of mental disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000. schools cannot be overemphasised. Proper education would 24. Guarnaccia PJ, Rogler LH. Research on culture-bound prevent the quacks from victimising the ignorant sufferers. syndromes: new directions. Am J Psychiatry. 1999;156:1322-7. Research opportunities exist in the cross-cultural validation of the disorder and identification of the pathophysiology. Bhuyan D, Deka B. Dhat syndrome: past and present - the journey of an Indian culture-bound syndrome across the globe. Open J Psychiatry Allied Sci. REFERENCES 2019;10:101-4. doi: 10.5958/2394-2061.2019.00021.1. Epub 2018 Jan 12.

1. Grover S, Gupta S, Avasthi A. Psychological correlates and Source of support: Nil. Declaration of interest: None. psychiatric morbidity in patients with Dhat syndrome. Indian J

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